Some health consumers find hidden costs in coverage

Justin Galloway, a manager at Neon Boots Dancehall & Saloon, bought insurance at the healthcare.gov web site and chose a preferred provider organization. He was previously uninsured.

Justin Galloway, a manager at Neon Boots Dancehall & Saloon,...

After two months of controversy, Texans say they are successfully signing up for health insurance through the federal marketplace and finding low premiums, but tucked into many plans are hidden time bombs: deductibles as high as $12,000 and restrictions on the doctors and hospitals in the plans.

Related

Justin Galloway of Houston, for example, bought coverage a few days ago, selecting a Blue Cross PPO plan at a cost of $61 per month to ensure he could see a doctor he likes. Galloway, 36, is employed, but his job doesn't offer insurance. He has been uninsured.

"The cheapness of the HMO is so attractive, but I really want my choice of doctor," he said, adding that the HMO premium would be $51 per month.

With improved access to the healthcare.gov website, it's become much more clear that consumers around Harris County have about half a dozen insurers and dozens of plans from which to choose. For example, a Harris County family of four has 42 plans from which to choose with a wide range of premium and deductible costs that hinge on a possible tax credit.

HMO vs. PPO

More Information

Health Insurance Marketplace

Consumers who intend to buy coverage on the federal health insurance marketplace should take the following steps to select and buy coverage:

1 Go to healthcare.gov, call 800-318-2596 or make an appointment with a counselor to create accounts, apply for tax credits, compare plans and buy coverage.

1 Consider premiums, deductibles, copays and out-of-pocket costs before selecting plans. A low-cost premium plan could become expensive for someone who requires frequent medical care and must meet a high deductible.

1 Look at each plan's provider network and prescription benefits. Patients with pre-existing medical conditions should ensure their doctors, hospitals, clinics and prescriptions are covered before buying a plan.

1 Call insurers for coverage explanations before buying a plan. Once you buy, you're locked in that plan until the next enrollment period, unless you marry, divorce or lose your job.

1 After buying coverage, call your insurer to confirm they received your information.

1 Phone the marketplace call center at 800-318-2596 if you have problems using healthcare.gov and can't complete or reset your enrollment application.

Analysis: HMO plan was cheaper but he decided on PPO to see the doctors he wanted.

How to navigate the marketplace

Consumers who intend to buy coverage on the federal health insurance marketplace should take the following steps to select and buy coverage:

1 Go to healthcare.gov, call 800-318-2596 or make an appointment with a counselor to create accounts, apply for tax credits, compare plans and buy coverage.

1 Consider premiums, deductibles, co-pays and out-of-pocket costs before selecting plans. A low-cost premium plan could become expensive for someone who requires frequent medical care and must meet a high deductible.

1 Look at each plan's provider network and prescription benefits. Patients with pre-existing medical conditions should ensure their doctors, hospitals, clinics and prescriptions are covered before buying a plan.

1 Call insurers for coverage explanations before buying a plan. Once you buy, you're locked in to that plan until the next enrollment period, unless you marry, divorce or lose your job.

1 After buying coverage, call your insurer to confirm they received your information.

1 Phone the marketplace call center at 800-318-2596 if you have problems using healthcare.gov and can't complete or reset your enrollment application.

In Harris County, premiums range from $486 per month for a Blue Cross HMO to $1,147 per month for a Blue Cross PPO (preferred provider organization) before tax credits would be applied for a family of four, according to healthcare.gov. The family deductible and out-of-pocket costs for the HMO each would be $12,700 annually without a tax credit. There would be no co-pays after the deductible and out-of-pocket maximums are met.

The PPO plan family deductible and out-of-pocket maximums would be $3,000 and $8,250 annually without a tax credit. Co-payments would be $25 per visit with a primary care doctor and $50 to see a specialist.

Those who want a range of provider choices and access to more elite facilities like the University of Texas M.D. Anderson Cancer Center are expected to have to pay higher premiums. More rural regions across the state have fewer companies and plans from which to choose.

Houston Methodist Hospital is participating in 12 plans offered by Blue Cross Blue Shield of Texas and nine Cigna plans - all preferred provider organizations. Administrators say they still are considering other insurers.

'Smooth as butter'

Translator

To read this article in one of Houston's most-spoken languages, click on the button below.

As consumers compare plans and sign up, the first glimpse of how the system is supposed to work is beginning to emerge. Based on interviews and responses on Facebook to questions posed by the Chronicle, no two stories are the same, depending on a variety of factors, including income, how much people want to spend, what level of coverage they are seeking and the number of people to be insured.

For some, though, it's an opportunity to enroll in health insurance for the first time. Others can regain lost coverage. Some are just looking as the Dec. 23 deadline looms to qualify for coverage starting Jan. 1. Otherwise, they can wait as long as March 31 to enroll.

Carol Briers of Brazoria County said she selected a Blue Cross HMO plan, which she believes will give her the coverage and provider network she needs. It is expected to cost about $200 per month with a $1,500 deductible if her subsidy is approved, she said. Briers, 64, has been insured under the federal Pre-existing Condition Insurance Condition Plan because of a 1999 breast cancer diagnosis. Her premium is $444 per month with a $3,500 deductible.

"It was as smooth as butter," she said of the enrollment process, which she started on the healthcare.gov website shortly after its Oct. 1 launch but recently completed after phoning a call center. "I would not be able to get insurance without this."

Hospitals surveyed

While no enrollment figures are available for Texas, Julie Bataille, spokeswoman for the agency overseeing the marketplace, last week said traffic at the healthcare.gov website had substantially increased, with close to 1 million visitors nationwide every day since a series of repairs were completed at the end of November. She declined to confirm new reports that 100,000 users in November had signed up for coverage.

On Monday, the Texas Hospital Association sent a survey to its members to determine how hospitals were selected for marketplace plans, said spokesman Lance Lunsford.

The Texas Medical Association, with more than 47,000 members, is preparing doctors for insurance enrollments and how they could affect members' practices. Doctors have been encouraged to determine whether they are included in marketplace plan networks and figure out how to identify patients who bought them, in case the patients can't maintain their premium payments.

Association President Dr. Stephen L. Brotherton, who practices in Fort Worth, said there also is concern that patients living in rural areas with more limited insurer and plan choices will have to find new doctors and travel longer distances to get to see them.

"The best information that we have right now is in 76 counties there is only one carrier," he said. "In 111 counties, there are only two carriers."

Goal of 7 million

An estimated 1.1 million uninsured residents live in Harris County and the surrounding area. More than 2.5 million Texans - families and individuals - are expected to be eligible to sign up for the nation's largest expansion of coverage in 50 years.

Nationally, the Obama administration hopes to enroll 7 million consumers in the first year.

Experts say it's too soon to know which marketplace plans will be the most popular.

Plans with broad coverage networks won't necessarily be the best selling, said Matt Eyles, executive vice president of Washington, D.C.-based Avalere Health. Many customers now are uninsured and accustomed to having few health care choices. And people who are relatively healthy might find that low-premium, high-deductible plans with narrow provider networks will be adequate.

"That's probably a good option for them," said Eyles, whose company provides health care consulting. "It's probably a significant improvement than what they have now."